Endocrine conditions

Question 1

What is the difference between primary and secondary hyperthyroidism?

Answer 1

Primary: pathology within the thyroid gland

Secondary: thyroid gland is stimulated by excessive thyroid stimulating hormone (TSH) in the circulation

Question 2

What % of hyperthyroidism is graves disease

Answer 2

60-80% cases

Question 3

What is the peak age onset of hyperthyroidism?

Answer 3

20-50

Question 4

Who does hyperthyroidism effect the most?

Answer 4

women 9:1

Question 5

Risk factors for Hyperthyroidism?

Answer 5

Family history
High iodine intake
Smoking
trauma to thyroid gland
toxic multinodular goitre
childbirth
HAART therapy

Question 6

What symptoms does hyperthyroidism present with?

Answer 6

Weight loss despite an increased appetite
Weight gain
Increased/Decreased appetite
Irritability
Weakness and fatigue
Diarrhoea/Steatorrhoea
Sweating
Tremor
Mental illness
Heat intolerance
Loss of libido
Oligomenorrhoea or amenorrhoea

Question 7

What signs does hyperthyroidism present with?

Answer 7

palmar erythema
sweaty and warm palms
fine tremor
Tachycardia (potentially AF or heart failure)
Hair thining or diffuse alopecia
Urticaria, pruritus
Brisk reflexes
Goitre
Proximal myopathy
Gynaecomastia
Lid lag

Question 8

What extra features are present in graves disease?

Answer 8

Eye changes- exopthalmos, opthalmoplegia, conjunctival oedema, papilloedema, keratopathy
Pretibial myxoedema
Thyroid acropachy
Thyroid bruit
Association with other autoimmune conditions

Question 9

What is thyrotoxic storm/hyperthyroid crisis?

Answer 9

An uncommon medical emergency caused by an exacerbation of hyperthyroidism

Question 10

What are the risks for thyrotoxic storm?

Answer 10

Infections
poor compliance
radio-iodine therapy

Question 11

How does thyrotoxic storm present?

Answer 11

Fever >38.5
tachycardia
delirium or coma
seizures
vomiting
diarrhoea
jaundice

Question 12

How is thyrotoxic storm treated?

Answer 12

Correcting of thyroid hormones using high doses of propylthiouracil
fluid resuscitation
treat precipitating causes

Question 13

What signs in hypethyroidism require urgent admission

Answer 13

Unwell/unable to manage at home
Presence of AF/cardiac failure
Dehydrated- eg from severe diarrhoea
Psychosis

Question 14

What is the management for Hyperthyroidism

Answer 14

Start Carbimazole 3x daily
Consider starting a beta-blocker or calcium channel blocker to control symptoms driven by the sympathetic nervous system
Monitor TFTs monthly

Question 15

Hyperthyroidism patient should be referred to a thyroid surgeon when..

Answer 15

there is symptoms of tracheal compression due to thyroid swelling
There is swelling associated with: 
a solitary enlarging nodule
previous neck irradiation
family history of endocrine tumour
hoarseness or voice changes
neck glands
young (before puberty)/old (>65) age

Question 16

Name a drug associated with drug induced hyper/hypothyroidism

Answer 16

Amiodarone

Question 17

What is the most common cause of hypothyroidism worldwide?

Answer 17

iodine deficiency

Question 18

What is the incidence of hypothyroidism in men and women

Answer 18

Women 2%

Men 0.2%

Question 19

Aetiology of primary hypothyroidism?

Answer 19

Autoimmune (Hashimotos thyroiditis)
Iatrogenic
Iodine deficiency
Drugs (amiodarone)
Congenital defects
Infiltration of the thyroid (amyloidosis, sarcoidosis, haemochromatosis)

Question 20

Aetiology of secondary hypothyroidism?

Answer 20

Isolated TSH deficiency
Hypopituitarism
Hypothalamic disorders

Question 21

With what symptoms does hypothyroidism present?

Answer 21

Tiredeness, lethargy, intolerance to cold
Dry skin and hair loss
Slowing of intellectual activity
Constipation
Decreased appetite with increased weight gain
Deep hoarse voice
Menorrhagia and later oligomenorrhoea or amenhorroea
impaired hearing
Reduced libido

Question 22

With what signs does hypothyroidism present?

Answer 22

Dry, coarse skin, hair loss and cold peripheries
Puffy face, hands and feet (myxoedema)
Bradycardia
Delayed tendon reflex relaxation
Carpal tunnel syndrome
Serous cavity effusions, eg. pericarditis or pleural effusions
5% will have opthalmopathy as in Graves

Question 23

How does myxoedema present?

Answer 23

Expressionless dull face with peri-orbital puffiness, swollen tongue, sparse hair
Pale, cool skin with rough, doughy texture
Enlarged heart
Mega-colon/intestinal obstruction
cerebellar ataxia
Psychosis
Encephalopathy

Question 24

How common is postpartum thyroiditis?

Answer 24

occurs in 5-7% of pregnancies within the first 6 months postpartum. Most women show complete remisission

Question 25

Investigations in Hypothyroidism?

Answer 25

Clinical and TFT test

Possibly imaging

Question 26

Treatment of Hypothyroidism?

Answer 26

Lovothyroxine once daily

Regular TFTs

Question 27

What percentage of thyroid lumps are malignant?

Answer 27

5%

Question 28

Risk factors for Goitres and thyroid lumps

Answer 28

Living in areas of low iodine consumption
Excessive consumption of iodine
Exposure to radiation
Family history
Smoking
Medication such as amiodarone and lithium

Question 29

What symptom requires urgent 1 day referral with a thyroid mass?

Answer 29

Stridor

Question 30

What causes Cushings syndrome?

Answer 30

Prolonged exposure to elevaqtedlevels of

Question 31

What is the incidence of cushings syndrome?

Answer 31

f 10 to 15 people per million, with a higher incidence in people with diabetes, obesity, hypertension or osteoporosis

Question 32

What is the most common cause of Cushings syndrome?

Answer 32

The use of exogenous glucocorticoids

Question 33

Endogenous cushings syndrom is divided into?

Answer 33

Corticotropin-dependant and corticotropin-independant

Question 34

80% of corticotropin dependant causes are due to?

Answer 34

Pituitary adenomas (cushings disease)

Question 35

What percentage of endogenous cushings syndrome is corticotropin dependant?

Answer 35

80-85% of cases

Question 36

How does Cushings syndrome present?

Answer 36

Truncal obesity, supraclavicular fat pads, buffalo hump, weight gain.
Facial fullness, moon facies, facial plethora.
Proximal muscle wasting and weakness.
Diabetes or impaired glucose tolerance.
Gonadal dysfunction, reduced libido.
Hypertension.
Nephrolithiasis.
Skin: skin atrophy, purple striae, easy bruising, hirsutism, acne; pigmentation occurs with ACTH-dependent causes.
Psychological problems: depression, cognitive dysfunction and emotional lability.
Osteopenia or osteoporosis.
Oedema.
Women may complain of irregular menses.
Thirst, polydipsia, polyuria.
Impaired immune function: increased infections, difficulty with wound healing.
Child: growth restriction.
Patients with an ACTH-producing pituitary tumour may develop headaches, visual problems, and galactorrhoea.
Destruction of the anterior pituitary may cause hypothyroidism and amenorrhoea.

Question 37

Causes of Pseudo-Cushings syndrome include:

Answer 37

Chronic severe anxiety and/or depression.
Prolonged excess alcohol consumption, which can cause a Cushingoid appearance.
Obesity.
Poorly controlled diabetes.
HIV infection.

Question 38

What are the recommended diagnostic tests for cushings syndrome?

Answer 38

24 hour urinary free cortisol
1mg overnight dexamethasone suppression test
late night salivary cortisol

Question 39

An undetectable plasma ACTH with elevated serum cortisol level is diagnostic of what?

Answer 39

ACTH-independant cushings syndrome (priary cortisol producing adrenal adenoma or exogenous glucocorticoid use)

Question 40

What is the definitive therapy for endogenous Cushings syndrome?

Answer 40

Tumour resection

Question 41

What drugs can be used to lower cortisol levels?

Answer 41

Metyrapone
ketoconazole
mitotane